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Dysentery.

Problems:

Synonyms:—Flux; bloody flux; rectocolitis.

Definition:—An infectious inflammation, with consequent ulceration of the large intestine, including the seg-moid flexure and the rectum, and occasionally extending to the small intestines above. It involves not only the mucous structures of the gut, but may include its walls and the peritoneum which envelops it. It is characterized by a sudden onset, with fever and intense irritation of the lower bowels, with an almost constant desire for movement, and the frequent passage of small mucous or bloody stools, accompanied with severe pain and a most aggravating tenesmus. As a result, prostration to exhaustion may soon follow, and there is rapid emaciation.

Etiology:—Two distinct types must be recognized: one caused by the bacillus of Shiga, and one by the ameba dysenteriae. A third class is sometimes named as due to the presence of the balantidum coli. This is a rare form of the disease; however, the infection in nearly every case is of a more or less mixed type.

The conditions which predispose to dysentery, are, of course, the environment of the patient, his habits of living, age, climate and the season of the year. The disorder is more frequent in the subtropics, the epidemic forms occurring in hot, damp weather. This disease is found, however, in every climate, but is seldom epidemic in temperate or cool climates. During the latter part of the summer or early in the fall, when the days are hot and the nights cool, the disease is most common. Tt occurs more frequently in males than in females, and is largely a disease of adult life.

It follows other infectious disorders, especially those which involve the mucous membranes, or which include to a greater or less extent the structures of the intestines, such as the eruptive fevers and typhus and typhoid. The disease is undoubtedly conveyed during epidemics, by water and by food. Probably uncooked fruits in the partial stage of decomposition conduce to it, and those conditions which from irritation of the mucous lining of the large intestine predispose to catarrh of the mucous lining of the lower bowel. These conditions, combined, as above stated, with sudden changes in the temperature, or with exposure to wet and cold, will materially promote the development of the disease.

Symptomatology:—There are certain symptoms which are pathognomonic of dysentery. While these may occur during the course of what has seemed to be a simple attack of diarrhea, the symptoms are usually abrupt in their appearance. With the effort at bowel movement, tenesmus, or straining, is first observed, and this is quickly accompanied with severe colicky pain, shooting through the lower bowels and ending in a severe cramp. There may be a chill, although this may not be markedly severe. The temperature quickly rises, usually to about 102° F. in the amebic form, or 103° F. in the bacillary form. There will soon be an intermission in the pain, but the desire for bowel movement is not satisfied, and quickly the patient finds that he must frequently go to stool, that each effort is accompanied with severe and increasing tenesmus, and that only a small quantity of mucus, or mucus and bloody stools, are passed. In the severe forms the stools are composed of blood alone. There is but little fecal matter. Pain precedes and follows the movement, and there is a distressing sensation of heat, burning or smarting in the rectum. The preliminary diarrhea, which may last from six to forty-eight hours before the characteristic dysenteric symptoms appear, will quite thoroughly evacuate the intestinal canal; and yet there are occasional cases in which, during the course of the disease, a considerable quantity of small, hardened masses of fecal matter resembling scybala will be passed, greatly increasing the irritation.

As the disease progresses the tormina and tenesmus increase to a marked extent, causing the patient to break out in a cold sweat, and inducing severe weakness and temporary exhaustion after every movement, which soon becomes permanent, involving both the heart and the nervous system. The irritation, general through the large bowel and rectum, soon involves the anus, producing spasm, and, through the spinal centers, may include also the cystic sphincter, resulting in difficult and painful urination. The impression of the pain upon the nervous system, causes a weak and rapid pulse, suspends the nutritive processes of the body, and emaciation is quickly apparent. There is much thirst, but an absence of desire for food. The tongue is coated usually with a brown coat, the membranes soon become dark, and in that form which has been sometimes described as typhoid dysentery, the symptomatic appearances of an ordinary case of typhoid fever will soon become plainly marked.

From its first appearance there is a rapid increase in the severity of all of the symptoms of this disorder, until about the third day the patient's suffering is intense; there is extreme exhaustion, emaciation is plainly apparent, the features are shrunken and the face has a pinched and anxious appearance, with an expression of general distress.

In epidemics of this disorder, the disease may show itself in one of two distinct forms; the commonest is that which has been described above, in which diarrhea for the first twenty-four hours, with rapidly increasing irritation of the bowels and prostration are the marked symptoms. With this the fever is apt to be of an asthenic type, and the tendency is more quickly toward typhoid development. In the other form the small intestines are often constipated, sometimes obstinately so; the fever, which appears quite abruptly, is of the sthenic type, and the prostration is not as rapid. The desire, however, for bowel movement soon becomes almost constant and the pain is very severe. In all cases the bowel movements quickly become fetid and ultimately the odor is very offensive.

The course of this disease varies with the degree of infection and with the character of the environment. When the infection from the bacillus of Shiga is virulent, the course of the disease is rapid, and death may occur in from three to four days. In amebic dysentery there is sometimes a mild development of the disease, which may continue several days, without producing any serious impression upon the system, the patient not being seriously ill. There may be from three to six or seven stools in a day, but the pain not being intense, the impression upon the system is not marked. This form of the disease is quite amenable to treatment, and may be relieved before it is necessary for the patient to be confined to his bed. Between this type and the extreme type named above as induced by the Shiga bacillus in the virulent form, is perhaps the commonest of all forms—the intermediate form. This form, however, will ultimately become serious and assume all the characteristics of the type that is early fatal.

A form of dysentery common in the tropics, known as acute tropical dysentery, or diphtheritic dysentery, presents pathologic characteristics quite different from those just described. It is caused by the bacillus dysenteriae of Shiga, and quickly develops typhoid manifestations. There is found present, on post-mortem, a croupous exudate of a grayish yellow color, which is distinctly diphtheritic in all of its appearances. Necrosis of the epithelium occurs, and deep ulceration with severe hemorrhage and ultimate perforation may follow. This diphtheritic infiltration thus involves all the structures of the intestinal wall, and in extreme cases it extends the entire length of the large intestines. In this form the system of the patient is markedly impressed with the disease; from the first there is general depression, and soon profound adynamia. There is involvement usually of the peritoneum; the abdomen becomes distended, sometimes greatly so, and exceedingly sensitive to pressure.

Dysentery is complicated by the development of peritonitis, or inflammation of the liver, with the formation of abscess, or as has been stated, by perforation of the bowel. The reflex irritation of the sphincter of the bladder is sometimes an additional cause of great distress. There may be also a slight involvement of the kidneys. In epidemic cases, pericarditis, endocarditis, septic pleuritis, or septic arthritis are not uncommon complications.

Diagnosis:—The pathognomonic phenomena of this disease are usually so plainly apparent that an incorrect diagnosis is next to impossible to a careful observer. The straining at stool is the first suspicious symptom, and this should be invariably regarded with suspicion if there is an epidemic of this disease. Following this is the unsatisfied desire, the frequent effort at bowel movement, with the passage of a very small quantity of mucus or mixed mucus and fecal matter, and later the diagnosis is confirmed by the presence of blood in the stools. The presence of extreme griping pains, fever, rapidly developing abdominal tenderness, with progressive prostration and emaciation, are all confirmatory. This group of symptoms is present in no other condition.

While a general diagnosis is not difficult, a specific diagnosis of the exact form of dysentery which is present is not so readily made. But as the disease is treated successfully from its symptomatic manifestations, whatever the form assumed, clinically this fact is usually of minor importance.

Prognosis:—In hot climates, with the unfavorable surroundings to which soldiers and laboring men are often exposed, the prognosis is often unfavorable. In endemic or sporadic cases, the prognosis can be considered good. When typhoid manifestations appear, in any form of the disease, the seriousness is materially increased; in diphtheritic cases the prognosis is bad.

Treatment:—It has been quite common practice to administer a cathartic at the onset of this disease. Unless there are strong evidences of fecal accumulation, this course should be avoided. It is an excellent plan, however, at the onset, to thoroughly flush the large bowel with sterilized water, to which hydrogen peroxid and half of a dram of the tincture of opium has been added. From the first the patient should have aconite and ipecac internally. These two remedies are the basis of early rational treatment. We have obtained excellent results by the use of small doses of ipecac frequently repeated, but the profession at large has advised as high as thirty grains of powdered ipecac three times a day. There is no doubt, however, that fully as desirable results are obtained from the remedy in smaller doses more frequently repeated. Whatever the other treatment, these two remedies should be continued for the first three or four days, unless the temperature falls to normal or below, when the aconite can well be exchanged for small doses of belladonna, especially if the skin and extremities are cool. As soon as the peritoneum is involved, bryonia must be given. It will exercise a beneficial effect, however, when there is general abdominal tenderness, with quick, sharp, cutting pains, whether the peritoneum is involved or not.

If the nervous irritation from the tenesmus is pronounced at the first, gelsemium is positively indicated. We have no remedy that will so satisfactorily control the straining at bowel movement and will relieve the irritation of the nerves, distributed to the large intestine and the bladder, as this remedy. By relieving this irritation it contributes, in many cases, most materially to the prevention of the development of the inflammation, and to its cure when developed. Another simple measure for the relief of the tenesmus is the injection of a pint of starch water which contains twenty drops of the tincture of opium, after a bowel movement. If the relief is not complete from a single injection, especially if the starch water has not been retained, it may be repeated at the next bowel movement. A suppository which contains opium is sometimes used for this purpose, with perhaps a small quantity of belladonna and an antiseptic, such as boric acid or iodoform.

The use of the sulphate of magnesium in small doses has become quite popular with many physicians. This is usually given, however, either in conjunction or in alternation with an acid remedy. In nearly all cases there is an early appearance of those evidences, in the mucous lining of the mouth and tongue, which we believe to be urgent indications for the use of acids. The aromatic sulphuric acid may be administered, especially if the tongue is very red and inclined to be dry, or sulphurous acid dilute if it is red and sleek. The aromatic sulphuric acid not only supplies an acid, but is a powerful antiseptic and a most desirable astringent, and is quite palatable. It has been demonstrated that whatever the bacillus present as the cause of dysentery, it cannot exist in an acid medium. The prevalence of an alkaline condition—an absence of acids—renders the growth and development of the germs of this disease possible. Thus other acids, such as nitric or hydrochloric acid, are beneficial in the treatment of this disease, and may be selected in accordance with the judgment of the prescriber.

The older physicians of our school were quite enthusiastic over the action of a compound which was known as white liquid physic. This was made of sodium sulphate, dissolved in water, to which nitric and hydrochloric acids were added. They gave us no explanation for the beneficial effect of this compound, which is so objectionable to the taste that but few physicians now prescribe it. All the desirable results of this remedy can be obtained by the agents named above, prescribed strictly in accordance with the specific indications. Its place is fully supplied by Epsom or Rochelle salts in small doses, with the proper use of an acid remedy. Large, objectionable doses are not needed.

In cases where typhoid indications are plainly marked, with the proper acid remedy echinacea and baptisia can be given with advantage. The former should be given in ten-drop doses every two or three hours. Occasionally it will be seen that the tongue, instead of being dry and dark, is moist and covered with a yellowish coat. At the same time there is some inclination to jaundice, with perhaps tenderness in the region of the liver. The older writers triturated podophyllin with sugar of milk in the proportion of one part of the former to one hundred parts of the latter, and administered this in doses of one or two grains every two hours. Where the tongue is moist and red and the tip is elongated, showing irritability of the stomach, it will be found that six or eight grains of the subgallate of bismuth every two hours will exercise a beneficial effect.

The thirst in these cases is a most distressing symptom. This should be met with cold water, to which hydrogen peroxide is added in the proportion of half of an ounce to a pint of water. This should be drunk to the exclusion of other beverages, except milk, or fruit juices diluted, to which hydrogen peroxide is added.

In the consideration of the diet of these patients, it is a good plan to permit no food to be taken for the first few hours, but to encourage the drinking of an abundance of water. Later milk may be diluted with water in the proportion of about one part of water to three or four of milk to which salt has been added. This can be drunk freely, unless curds are formed in the stomach, but as there is usually a deficiency of the acid constituents of the gastric juice, this is not as apt to occur as it is in other forms of diarrhea. If this condition threatens, a little lime water may be combined with the milk, or the patient may take an occasional dose of neutralizing cordial. These remedies, however, are seldom of benefit in this disease.

Solid foods must be avoided. Raw eggs may be beaten thoroughly and added to the milk, or soft boiled eggs may be taken occasionally. Meat juices are beneficial if the stomach will receive them kindly. There is always present in these cases an impaired digestion; at the same time, so rapid is the prostration that the demand for concentrated nourishment is imperative. It is necessary, therefore, that all irritation of the stomach be avoided, and the best of judgment be exercised in selecting those foods which will be readily appropriated, or in supplying those assistants to digestion which will insure the proper appropriation of the food.

All discharges during the course of this disease should be passed into a vessel which contains a strong antiseptic, and in epidemic cases these should be buried. The strictest of antiseptic precautions and the utmost cleanliness in the care of the patient, and precautions for the cleanliness of the patient's immediate surroundings, must be adopted.

Chronic Dysentery.

Dysentery sometimes assumes a chronic form. It seldom, if ever, so occurs independent of an acute attack, to which it it secondary.

Symptomatology:—It presents a group of symptoms quite different from those described in the acute disorder. The pathognomonic evidences are not plainly marked. The bowel movements are small and consist of mucus and membranous shreds, and some blood. There is colic and some abdominal tenderness. The strength of the patient is reduced, and the general condition is that of chronic invalidism. It is not uncommon for exacerbations to occur, in which symptoms resembling the simpler forms of the acute disease will be present for a day or two, when there will be an abatement of these phenomena, and the disease will assume the usual chronic manifestations. It is not infrequent that the bowels are distended with gas; later the digestion becomes impaired and a train of symptoms similar to those of chronic gastritis will appear in addition to the dysenteric symptoms.

Treatment:—It is a good plan to adopt a course of systematic intestinal irrigation in the chronic form of this disease. The use of acid remedies internally, with an antiseptic added to the injection, will enhance their influence. Internally the use of an acid remedy with the sodium sulphite, or magnesium sulphate will be beneficial. It is a good plan to give ipecac in conjunction with the bisulphate of quinin and hydrastin. Quite a general influence is exercised by this combination. The ipecac relieves the irritability of the mucous membrane and restores its tone and normal functional activity. The quinin has a specific toxic influence upon the germs of the disease, as the sulphate has upon the plasmodium malaria. It also stimulates the nervous system and encourages its influence upon the functionating of the nutritive organs. The hydrastis is both a nerve restorative and a gastro-intestinal tonic. Its influence is very wide, both directly and indirectly. Nux vomica may be given also in selected cases. Its influence is direct upon the stomach, materially enhancing the influence of hydrastin. Much care must be exercised in these cases in the selection of food, and the physician should retain his supervision of the diet for weeks after the conspicuous symptoms of the disease have abated.


The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.



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